Vantage Snippets are short summaries of breaking news stories.

Focus turns to Rett as panel gives Acadia’s Nuplazid a thumbs down

Acadia’s attempt to expand Nuplazid’s label into Alzheimer’s disease psychosis looks to have failed, following an FDA panel vote last Friday that went 9 to 3 against the idea. This was always a long shot after the complete response letter for the group’s previous application in the wider dementia-related psychosis setting; the Alzheimer’s submission relied heavily on a subgroup analysis and the FDA had already said it wanted another trial conducted. The company has yet to say whether this will happen; Alzheimer’s disease psychosis might have big commercial potential but investors are unlikely to want to see more money spent here. Either way, another CRL looks to be on the way, making negative symptoms of schizophrenia Acadia’s next label expansion bid; Nuplazid managed only a very narrow win in the first pivotal trial conducted here. Regarding the psychosis panel, the most supportive comments that Stifel analysts could muster were that the absence of negative surprises validated management’s credibility, though the logic that this is "incrementally positive" for the group’s next project, trofinetide in Rett syndrome, is pretty hard to follow. A filing for trofinetide is due mid-year, making acceptance from the FDA the next big event for Acadia.

Up next for Acadia
Project Setting Details
Trofinetide Rett syndrome Submission due mid-2022, priority review expected (Lavender trial succeeded Dec' 21)
Nuplazid Negative symptoms of schizophrenia Ph3 Advance-2 trial due to read out Q1'23 (Advance narrowly succeeded)
ACP-044 Osteoarthritis pain Ph2 trial due to read out H1'23 (Failed in post-surgical pain in Apr' 22)
Source: Evaluate Pharma. 

Testing times for Roche despite new Covid assay

The first test that can not only diagnose Covid but directly measure viral load has been granted emergency authorisation in the US – and its maker, Roche, needs the win. The cobas Sars-Cov-2 DuoA is a PCR test using nasal and nasopharyngeal samples that runs on the Swiss group’s cobas 6800 and 8800 systems, and should roll out in the US this month. Roche says that quantitative testing could identify infected patients earlier and more accurately than current tests. This could aid in the triage of patients, for instance by enabling swift administration of antivirals – a boon to vulnerable patients with pre-existing health conditions who need therapy fast. The launch of this test might do something to forestall the forecast drop in Roche’s test revenues. According to consensus data from Evaluate Medtech, Roche’s molecular diagnostics sales nearly doubled from 2019 to 2020 as it launched various Covid PCR tests to combat the burgeoning pandemic. However, the sellside forecasts that these sales will fall in 2022 and 2023, only returning to growth in 2024. 

Roche dents the amyloid hypothesis again

With some big late-stage readouts due in Alzheimer’s disease in the coming year, Roche and AC Immune have reminded investors of the perils of this space. True, hopes were not high for the anti-amyloid MAb crenezumab, which had already flunked the pivotal Cread studies several years ago. But the latest failure, of a mid-stage trial in presymptomatic patients with a specific mutation, could make the likes of Lilly, Biogen – and indeed Roche – nervous. Roche and AC Immune are not saying much about the data, although the partners appear to disagree about whether numerical differences favouring crenezumab were “small” or not. More details are due at the AAIC meeting on August 2. The latest flop hits the theory that intervening early could halt Alzheimer’s, though the amyloid debate will rumble on, particularly as crenezumab has not been shown to reduce amyloid plaques. This has been seen with Roche’s gantenerumab, Lilly’s donanemab and Biogen/Eisai’s lecanemab. Whether plaque reduction has an impact on Alzheimer’s symptoms remains to be proven, something that pivotal data with these projects will hopefully help clarify.  

Upcoming big readouts of amyloid-targeting projects in Alzheimer's
Project Company/ies Clinical trial details Note
Lecanemab (BAN2401) Biogen/Eisai Topline readout from ph 3 Clarity-AD due Q3 2022 Rolling BLA for AA submitted May 2022; filing for full approval slated for Q1 2023
Donanemab Lilly Topline data from Trailblazer-Alz 4, H2H vs Aduhelm, due H2 2022; Topline data from pivotal Trailblazer-Alz 2 due mid-2023 Rolling BLA for AA to be completed Q2 2022
Gantenerumab Roche Topline data from Graduate 1 & Graduate 2 due Q4 2022 Roche not pursuing AA
AA=accelerated approval; BLA=biologics licence application. Source: company releases &

Boston makes a Korea change

In a reminder that stents aren’t just for the vasculature, Boston Scientific has bought MI Tech, a maker of devices designed not for blood vessels but to prop open other passages such as the oesophagus and bile ducts. Boston has acquired 64% of the South Korean group from its current owner, Synergy Innovation, for KRW291.2bn ($230m). Though this is a smallish bolt-on by Boston’s historical standards, so quiet has 2022 been for M&A that, astonishingly, it qualifies as the seventh-largest acquisition of the year so far. Otherwise Boston has followed its usual MO of buying a group with which it has an existing relationship: the US company has distributed MI Tech’s Hanarostent franchise in Japan since 2015. Boston’s shares rose 4% on the news.

Top 10 M&A deals of 2022
Announcement date Acquirer Target Value ($m) Focus
Jan 1 Owens & Minor Apria 1,450 Anaesthesia & respiratory
Apr 18 Archimed Natus Medical 1,200 Anaesthesia & respiratory, neurology
Feb 7 The Cooper Companies Reproductive Health business of Cook Group 875 Obstetrics & gynaecology
Jan 10 Medtronic Affera 675 Cardiology
Apr 1 Biomérieux Specific Diagnostics 426 In vitro diagnostics
Jan 5 Vera Whole Health Castlight Health 370 Healthcare IT
Mar 31 Fresenius Ivenix 240 Drug delivery
Jun 15 Boston Scientific MI Tech 230 Gastroenterology
Jan 9 Exact Sciences Prevention Genetics 190 In vitro diagnostics
Apr 18 Fulgent Genetics Inform Diagnostics 170 In vitro diagnostics
Source: Evaluate Medtech & company communications. 

A new multiple sclerosis device steps forward

Nine companies have developed powered exoskeletons that are cleared for sale in the US, with almost all of these devices intended to aid walking by patients with spinal cord injury or stroke. But last week Ekso Bionics moved into an entirely new indication, as the FDA cleared its EksoNR robotic exoskeleton for use by multiple sclerosis patients. The clearance, more specifically for rehabilitation use in patients with MS, will significantly expand the device’s reach, Ekso said. It already claims that EksoNR is the latest-generation version of the “most clinically used” robotic exoskeleton on the market. Nearly a million people in the US are living with MS, according to the National MS Society, though only a small minority of these patients would be expected to develop mobility issues serious enough to warrant the use of an exoskeleton. News of the clearance prompted Ekso’s share price to close up 23% yesterday. Unfortunately the stock has lost 99% of its value since Ekso floated in early 2014, with sales having disappointed. The company is not profitable, and reported sales of just $2.6m in the first quarter of this year.

FDA-cleared powered exoskeletons
Company Device Indication and date cleared
Rewalk Robotics ReWalk SCI in Jun 2014* and Jul 2016
ReWalk Restore Hemiplegia or hemiparesis due to stroke in June 2019
ReWalk P6.0 SCI in May 2020
Parker Hannifin Indego SCI in Feb 2016 and Sep 2017; SCI and hemiplegia due to cerebrovascular accident in Jan 2018
Ekso Bionics Ekso and Ekso GT SCI and hemiplegia due to stroke in April and again in Jul 2016
EksoNR Acquired brain injury, including traumatic brain injury and stroke, and SCI, in Jun 2020; multiple sclerosis in Jun 2022
Cyberdyne Hal SCI in Dec 2017; SCI, post-stroke paresis and paraplegia due to progressive neuromuscular diseases in Oct 2020
Honda  Honda Walking Assist Device Stroke with gait deficits in Dec 2018
US Bionics Phoenix SCI in Apr 2019
B-Temia Keeogo Dermoskeleton Stroke with gait deficits in Sep 2020
Exoatlet Asia ExoAtlet-II SCI in Jul 2021
Samsung Electronics Gems-H Stroke with gait deficits in Apr 2022
SCI = spinal cord injury. *De novo clearance; all others are 510(k) clearances or supplements. Source: Evaluate Medtech, FDA. 

The EksoNR system

Endo 2022 – Voxzogo’s prospects shrink

The prospects for Biomarin’s achondroplasia therapy Voxzogo in very young children had already looked murky after a vague update earlier this year. Now the company has given – some – further details, and things are still far from clear. The results, presented in a poster at the Endo meeting, came from a phase 2 study in under-fives. Biomarin touted a placebo-adjusted 0.92cm/year increase in annualised growth velocity – below the 1.57cm/year seen in a separate trial in patients aged five and over, for whom Voxzogo is already approved. What is more, the former figure included so-called “sentinel subjects” – patients who received open-label Voxzogo at the start of each new age group cohort. Biomarin did not disclose growth velocity results for randomised patients only, suggesting that these were “less good, and/or more fraught with noise”, as Stifel analysts put it. The company did give more details of Z-scores, a measure of how much a given value deviates from the mean, used to track the growth of very small children. However, the Z-score was less impressive when only randomised patients were included. Stifel reckons the latest data are “probably enough” for label expansion, but without more information this looks tough to call.

Cross-trial comparison of Vozxogo's effect in over and under fives
  Ph2 in pts <5 (NCT04554940) Ph3 in pts ≥5 (NCT03197766)
  Randomised pts only Incl sentinel subjects 
Annualised growth velocity (cm/year) Not given 0.92 1.57
Height standard deviation score* 0.25 0.30 0.28
*This is referred to as Z-score by Biomarin. All values placebo adjusted. Source: company release & product label.

Firefly glows for Day One

Day One Biopharmaceuticals’ stock received a much-needed boost today on data suggesting that tovorafenib might be a viable therapy for paediatric low-grade glioma. The company calls tovorafenib a type II pan-Raf inhibitor, and says most paediatric low-grade gliomas are driven by Braf alterations. The first 22 evaluable patients in the mid-stage Firefly-1 trial generated an overall response rate of 64%, comprising one unconfirmed and 13 confirmed partial responses. The trial has no control arm, but there are no approved therapies for this cancer type; Firefly-1 patients had a median of three prior lines of therapy. A larger dataset is due early in 2023, and the company hopes to file by mid-year, while a front-line pivotal study of tovorafenib, Firefly-2/Loggic, will soon get under way. Despite doubling in value today Day One is still worth 20% less than when it floated just over a year ago, though some have had skin in this game for considerably longer than IPO investors. The asset has an almost two-decade history, having been through the hands of Biogen and Takeda. Viracta, which sold off Sunesis's rights last year, might be kicking itself today.  

Tovorafenib's convoluted history
2004 Sunesis and Biogen form small-molecule discovery deal, originating tovorafenib (then known as BIIB024)
2011 Biogen spins out two oncology assets, including the still preclincal tovorafenib, to Takeda; development continues in collaboration with Sunesis, which receives $4m up front and is eligible for $60m in milestones
2012-2015 Takeda moves the asset, coded MLN2480 or TAK580, into the clinic for melanoma
2019 Day One buys tovorafenib from Takeda and amends Sunesis deal; Sunesis recieves $2m up front and could get $54m in milestones and future royalties
2021 Sunesis collapses, and is reversed into by Viracta
2021 Viracta sells potential future milestones and royalties to tovorafenib to Xoma for $13.5m plus $20m pre-commercialisation milestone
Jun 1, 2021 Day One raises $184m in Nasdaq IPO; tovorafenib named DAY101
Jun 12, 2022 Positive interim Firefly-1 data
Source: company statements & Evaluate Pharma. 
Source: company presentation.

EHA 2022 – Crispr’s second off-the-shelf Car-T disappointment

Crispr Therapeutics has seen impressive activity in heavily pretreated patients with T-cell lymphoma, a tough malignancy, given its CD70-directed allogeneic Car-T therapy CTX130. Unfortunately, this project has been hit with the same relapse problems as Crispr’s own and others’ off-the-shelf Cars: of the nine remissions in the company’s Cobalt-Lym trial reported at the EHA meeting on Saturday just one can be said to be long-lasting, a PR of eight months’ duration from CTX130 infusion. One short-term response is ongoing without further intervention, while one was achieved only after a second Car-T cell infusion. The remaining six responses have all relapsed, though three were retreated, and two of these went on to be transplanted. As such, Crispr’s headline ORR number of 50% across all doses, or 70% at level 3 or above, does not tell the whole story. Investors in all allo Car-T companies will be used to this story, with Caribou falling into the relapse trap just last Friday. Crispr itself has already suffered this fate with its lead off-the-shelf Car, CTX110, which hits CD19. Allogene, whose anti-CD70 Car ALLO-316 is in phase 1 for kidney cancer, will pay particularly close attention.

Source: EHA & company presentation.

Bluebird backing boosts beleaguered gene therapy space

The unanimous backing of Bluebird's gene therapies by FDA panels last week not only throws that company a lifeline, it also gives a boost to a section of the biotech world that has taken a particularly big hit to sentiment. True, final approvals of the lentiviral projects are still pending, and reimbursement will be another issue, but comments at the hearings suggest that US physicians and patients are open to using gene therapies despite ongoing safety concerns, largely around the risk of cancer, and questions about lack of durability. For the first project, eli-cel, for a very rare childhood condition, lack of other options for those without a matched donor for stem cell transplant helped win the risk-benefit argument. A green light for beti-cel for beta thalassaemia also looks likely after the project impressed on durability, with some patients transfusion free after four years. Bluebird shares opened up 40%, but the company remains in dire financial straits. The market for eli-cel is tiny, and competition is coming behind for beti-cel. Approvals and the swift sale of subsequent priority review vouchers must happen without delay for these gene therapy stories to have a chance of a happy ending.

Bluebird's days of reckoning: the outcomes   
Project Vote Next step 2028e sales  
Beti-cel (beta-thalassaemia gene therapy) 13-0 in favour of benefit over risks FDA decision due by Aug 19  $120m*
Eli-cel (CALD gene therapy) 15-0 in favour of benefit over risks FDA decision due by Sep 16  $21m
Note: *beta-thalassaemia sales only; CALD=cerebral adrenoleukodystrophy. Source: company communications.

Outstanding questions overshadow GSK’s respiratory syncytial virus win

The soon-to-be pure-play pharma company GSK desperately needed a hit in respiratory syncytial virus – the vaccine for older adults is considered its most valuable pipeline project. Relief all round then at news of success for the phase 3 Aresvi 006 trial, though lack of detail makes the extent of the win unknowable. GSK described the result as “statistically significant and clinically meaningful”, adding that the effect size was consistent across secondary endpoints and in those aged 70 and above. The company has previously described efficacy above 50% as clinically meaningful, 70% very good and above 80% outstanding; analysts want to see at least 70%, believing that anything less would leave GSK susceptible to projects coming behind. Durability of response is another consideration, with some analysts concerned that regulators might want to see data over more than one RSV season. GSK is confident that its vaccine, which uses the same adjuvant as Shingrix, will provide long-term protection; this is an issue that all contenders must address, of course, and could be an important differentiator in the long term. With Pfizer and J&J also expecting pivotal readouts later this year, the race to market will soon be on.

Late-stage pipeline of adult RSV vaccines
Product Company Description Details 
GSK3844766A GSK Protein subunit vaccine, adjuvanted Ph3 Aresvi in adults ≥60 toplined positive June 2022
RSVpreF ((PF-06928316) Pfizer Protein subunit vaccine Ph3 Renoir trial in adults ≥60, data due H2 2022 
Ad26.RSV.preF J&J Adenovirus type 26 viral vector vaccine  Ph3 Evergreen trial in adults ≥60, data due H2 2022
MVA-BN RSV Bavarian Nordic Recombinant antigen vaccine Ph3 trial in adults ≥60, data due H2 2023
mRNA-1345 Moderna mRNA vaccine encoding RSV glycoprotein F Ph3 portion of ph2/3 ConquerRSV trial in adults ≥60 began Feb 2022
Source: Evaluate Pharma.
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